In the past few years public awareness of sexual abuse of children has increased, together with the recognition of its social, physical, and psychological effects (I). We must emphasize our role as diagnosticians in doing a comprehensive assessment of the sexually abused child. It is our professional responsibility to assess the general psychological status of the child before and after sexual abuse

Colon-De Marti, MD, Luz N.

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CHILD PSYCHIATRYTHE IMPORTANCE OF COMPREHENSIVE ASSESSMENTOF THE SEXUALLY ABUSED CHILDLUZ N . COLON-DE MARTI, M.D.INTRODUCTIONIn the past few years public awareness of sexual abuse of children has incre ased,together with the recognition of its social , physical , and psychological effects ( I ). Wemust emphasize our role as diagnosticians in doing a comprehensive assessment of thesexually abused chi ld. It is our profe ssional responsibility to assess the generalpsychological status of the child before and after sexual abu se.CASE REPORTAlice, a seven-year-old girl, was brought to the Emergenc y Room after havingbeen sexually abused by a stranger who broke into her house while her parents wereabsent. She was admitted to the Pediatric Service for surgical repair of severe vaginallacerations. During her hospital stay she was seen by the Child Psychiatr y Consulta-tion and Liaison staff (2), who ascertained that Alice had evide nce of unresolvedpsychological conflicts that were proba bly present before she was sexua lly abused, aswell as having some of the most frequentl y observed reactions of the sexually abusedchild . A meeting was arranged with Alice 's mother prior to her dischar ge, where it wasagreed that Alice would continue in individual tre atment.A psychotherapeutic relationship with Alice was establi shed through the use ofher spontaneously made drawings. She used her drawings as a gra phic expression ofher worries and concerns. She manifested some of the frequentl y described behavioralreactions seen in children exposed to psychological trauma (3): nightmar es (where themother descr ibed her as if "she was pushing the sky with her hand s and kicking withher legs" ) (4) ; scared to be alone, scared to sleep by herself, and sca red of strangers.She expressed some concern about the heali ng of her vagin al lacer ati ons. It was alsothro ugh her dr awings that Alice was able to discuss some of her prior emotionalconflicts, for example, her reaction to the separation of her par ents several yearsearlier. After three months of psychotherapy, Alice was able to work th rough hermajor post- traumatic st ress symptoms. She contin ued in therapy because of pre-existing conflicts .Dr. Ma rti is a senior child fe llow .52Comprehensive Assessment of Sexually Abused ChildDISCUSSION53It is important to do a comprehensive assessment of the sexua lly abused child,exploring the pre-traumatic emotional status of the child, as well as the impact of beingsexua lly abused. As is frequently seen in abused children and ra pe victims, Alicepresented symptoms that met DSM-III criteria for a post-traumat ic stress disorder (5,6) . According to Sgroi, the se children need psychotherapeutic help to address "impactissues " such as guilt, depression, low self esteem, poor social skills, repr essed anger andhostility, impaired ability to trust, blurred role bound ari es and role confusion,pseudomaturity with failure to accomplish developmental tasks, and self mastery andcontrol (7). Sgroi also considered "the damaged goods syndrome" as one of the"impact issues ," wherein because of the physical damage cau sed to the chi ld he or shecan come to believe that they were damaged. Alice susta ined vag ina l lacera tions thatshe referred to in her first contact with the therapist. '" was bleedin g from there," shesaid , pointing to her genital area. "It hurts . . . but .. . it will get better ; th e doctor toldme . . ."Another important issue that needed to be addressed was th e effect of Alice'shospitalization. Anna Freud has sta ted that hospit alization can be an emotionallyhazardous event, not only because of the emotion al reactions to th e illness itself, butbecause the child is exposed to separation from his fam ily, an event that may have aprofound effect on the child's development (10). Through her dr awings Alice was ableto relate her most disturbing behaviora l reactions and discu ss " impact issues." DiLeohas sta ted that drawings are "one means of establishing a rapid , easy and pleasa ntrapport" (8 , 9). In Alice's case they facilit ated the establishment of a therapeuticalliance and psychotherapeutic treatment, as will be discu ssed in a separate communi-cation .The stress of sexual abuse creates a crisis, the severity of which depends on man yfactors, including how successful the victim had been in solving crisis situa tions in thepast (2, II) . This is another reason supporting the need for the comprehe nsiveassessment of the sexually abused child . The recovery from such a tr aumaticexperience can be compromised, as Burgess and Holmstrom found in th eir follow-upstudy of rape victims , by the impact of life stresses prior to the tr aumat ic event (I 2) .Some sexually abused children, like Alice, need to address those pre-trau mat ic issuethat could further compromise their psychological and social development. AnnaFre ud wrote :The whole personality of the child should be scrutinized for cert ain generalcharacteristics which are of possible significance for predicting the chancefor spontaneous recovery and reaction to treatment . .. (I3)Our role is thus defined as one of doing a comprehensive and clinica lly meaningfulassessment that includes the recognition of factors and processes tha t may effectpsychologica l grow th. The psychiatric evaluation, therefore, should includ e an assess-ment of the emotional state of the child before and after being sexua lly abused .Moreover, it is our responsi bility to facilitate their recovery not only from thei rtraumatic experience, but to promote their general emotional development as well.54REFERENCESJefferson Jou rna l of Psychiatry1. Se idl T , Parad ise J E: Child sexual abuse: effective case managment by a multid isciplinar yteam . Res S taff Phys 30: 48- 51, 19842. Ravenscroft: Psychiat ric consulta tion to the child with ac ute physical illness and hospital-izati on . Psych Ann 12: 1065-1073, 19823. Terr LC: Psychic trauma in children: observations following the Chowchilla school buskidnapping. Am J Psych 138: 14- 19, 19814. Fenichel 0 : Th e Psychoanalytic Theory of Ne urosis. New York, Brunner/ Mazel, 19835. Burgess AW: Rape . . . Crisis and Recover y. Ma ryland, Robert Brady, 19796. Green A: Child abuse, dimension of psychological trauma in abused children. J Am Ac ChPsych 22: 23 1-237, 19837. Sgro i S : Handbook of Cl inical Intervention in Child Sex ual Abu se. Toronto, lexingtonBooks, 19828. Dileo JH : Interpreta tion of Childrens Drawings. New York, Brunner/ Mazel, 19839. Dileo JH: Young Children and Th eir Drawings. New York, Brunner / Mazel, 197010. Freud A: Role of body illness in the ment al healt h of children. Psychan S t Ch 7: 149- 152,196211. Lindema nn E: The mean ing of crisis in ind ividual and fami ly. Teachers College Record310: 1956-712. Burgess A, Hoslst rom WLLL: Recovery from ra pe and prior life stresses. Rs N urs Health I:165- 174,1 97813. Freud A: Assessment of childhood disturbances. Psychoan St Ch 7: 149-1 58, 1962

The Importance of Comprehensive Assessment of the Sexually Abused Child

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The Importance of Comprehensive Assessment of the Sexually Abused Child

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